KATHY HOCHUL
Governor
KERRI E. NEIFELD
Commissioner
OFFICE FOR PEOPLE WITH DEVELOPMENTAL
DISABILITIES ELIGIBILITY GUIDELINES
Determining Eligibility for Services:
Substantial Handicap and Developmental Disability
SCOPE OF GUIDELINES
This document offers clinical and procedural guidance about determining and reviewing basic
eligibility for the Office for People With Developmental Disabilities (OPWDD) supports and
services. A basic determination of eligibility for developmental disability as defined in Mental
Hygiene Law (MHL) 1.03(22) does not mean that the person is eligible for every type of OPWDD
service. Additionally, the person seeking OPWDD eligibility must be a New York State resident
or intend to reside in New York State at the time services are delivered.
Some OPWDD supports and services have additional eligibility criteria. For example, Intermediate
Care Facility (ICF) settings and Home and Community-Based Services (HCBS) waiver programs
require an additional level-of-care determination, and individuals are eligible for HCBS services
only when they reside in qualifying living arrangements. Reviews and determinations based on
these and other additional criteria associated with eligibility for specific OPWDD services are not
part of the initial eligibility process and, therefore, not a topic of these guidelines.
These guidelines also provide updated information about:
• Determining eligibility when it is unclear whether the presence of intellectual or
developmental disability can be verified;
• Determining eligibility when historical clinical records and related materials have not been
provided for review, or cannot be obtained for review;
• Criteria to determine the presence of a “substantial handicap;”
• The nature of “neurological impairment” as a qualifying condition;
• Clinical practices related to the diagnosis of Autism Spectrum Disorder (ASD);
• Age parameters and criteria related to provisional eligibility; and
• Establishment of procedures related to the review of individuals who have previously been
found eligible, or who have received services from OPWDD in the past.
OPWDD Guidance: Eligibility Guidelines Page 2 of 27
Contents
SCOPE OF GUIDELINES .......................................................................................................... 1
SECTION I: DEFINITION OF DEVELOPMENTAL DISABILITY ................................................ 3
SECTION II: PROFESSIONAL PRINCIPLES ............................................................................ 4
A. Assessment and Diagnosis .......................................................................................... 4
B. Need for Complete Clinical Information ........................................................................ 4
C. Required Documentation ............................................................................................. 5
D. Practitioners Qualified to Conduct Standardized Testing ............................................. 5
E. Need to Use Prevailing Diagnostic Nomenclatures and Accepted Diagnostic Practices 6
SECTION III: FUNCTIONAL LIMITATIONS, INTELLECTUAL AND ADAPTIVE FUNCTIONING
AND SUBSTANTIAL HANDICAP ............................................................................................. 8
A. Functional Limitations .................................................................................................. 8
B. Assessing Intellectual Functioning and Adaptive Functioning ...................................... 8
C. Using Scores on Adaptive Behavior Measures to Establish Necessary Functional
Limitations ............................................................................................................................. 9
D. Substantial Functional Limitations and Qualifying Conditions ....................................... 9
E. Appropriate Standardized Assessment Measures .......................................................10
F. Establishing Substantial Functional Limitations for Provisionally Eligible Children ......12
SECTION IV: DDRFO REVIEW PROCESS ..............................................................................14
A. Established Review Procedures ..................................................................................14
i. Eligibility Application ...................................................................................................14
ii. 1
st
Step Review ...........................................................................................................15
iii. 2
nd
Step Review ..........................................................................................................16
iv. 3
rd
Step Review ..........................................................................................................16
v. Provisional Eligibility for Children Through Age 7 ........................................................17
vi. Maintaining Eligibility Records ....................................................................................17
B. Redeterminations of Eligibility .....................................................................................17
i. Provisional Eligibility ...................................................................................................18
ii. New Information .........................................................................................................18
iii. Significant Break in Service..........................................................................................19
iv. Eligibility Status and Limited Services/Service Requests ............................................19
SECTION V: FACTORS THAT PROMPT SECOND STEP REVIEW ........................................21
SECTION VI: REFERENCES ...................................................................................................23
Appendix A: Application Checklist for Determination of OPWDD Eligibility ......................24
OPWDD Guidance: Eligibility Guidelines Page 3 of 27
SECTION I: DEFINITION OF DEVELOPMENTAL DISABILITY
Section 1.03(22) of the New York State Mental Hygiene Law is the legal basis for OPWDD’s
eligibility determination and defines Developmental Disability.
“Developmental disability” means a disability of a person which:
(a) (1) is attributable to intellectual disability, cerebral palsy, epilepsy, neurological
impairment, familial dysautonomia, Prader-Willi syndrome or autism;
(2) is attributable to any other condition of a person found to be closely related to
intellectual disability because such condition results in similar impairment of
general intellectual functioning or adaptive behavior to that of intellectually disabled
persons or requires treatment and services similar to those required for such
person; or
(3) is attributable to dyslexia resulting from a disability described in subparagraph one
or two of this paragraph;
(b) originates before such person attains age twenty-two; and
(c) has continued or can be expected to continue indefinitely; and
(d) constitutes a substantial handicap to such person's ability to function normally in society.
OPWDD Guidance: Eligibility Guidelines Page 4 of 27
SECTION II: PROFESSIONAL PRINCIPLES
At least one federal agency and several professional associations provide clarification and
support for the interpretation of this section of the law. These include the:
• Administration on Intellectual and Developmental Disabilities (AIDD);
• American Association on Intellectual and Developmental Disabilities (AAIDD);
• American Psychiatric Association (APA); and
• American Psychological Association (APA).
A. Assessment and Diagnosis
MHL
1.03(22) addresses eligibility for services for people with intellectual disability and
people with other developmental disabilities who do not have intellectual disability.
A valid diagnosis of a qualifying condition named in MHL 1.03(22)(a)(1) is required; or
alternatively, for people seeking eligibility based on a related condition, as defined in
1.03(22)(a)(2), a diagnosis of a specific condition is required.
Other requirements include:
• onset of the condition prior to the person turning age 22;
• likelihood of indefinite continuation of the condition and the associated substantial
handicap; and
• presence of substantial functional limitations which can be clearly attributed to the
identified qualifying diagnosis.
Combined, these factors confirm OPWDD eligibility.
B. Need for Complete Clinical Information
Eligibility determinations must be made based on complete and sufficient clinical
information. Such information is necessary to determine whether the person meets the
requirements established in MHL 1.03(22). This information must include:
• History and presence of developmental disability with an onset prior to the age of
22;
• Medical, medical specialty, or health information identifying the nature and
diagnosis of a condition resulting in neurological impairment, or other
physical/medical condition associated with a qualifying condition;
• Standardized intelligence testing as a component of a comprehensive
assessment of the clinical condition; and
• Standardized measures of adaptive functioning that can detect substantial
handicaps or functional limitations that can be attributed to the identified condition.
It is the responsibility of the referring party to provide or arrange for the provision of such
information. A Developmental Disabilities Regional Field Office (DDRFO) may assist
referring parties in securing such information and may request additional information as
OPWDD Guidance: Eligibility Guidelines Page 5 of 27
necessary to determine whether a person is OPWDD eligible.
C. Required Documentation (Also See Appendix A)
In most cases, the DDRFO will need the following information to determine whether
someone is eligible for OPWDD services:
1. Medical or specialty reports (for example, a neurological or genetic testing report),
including health status and diagnostic findings, to support a qualifying diagnosis
other than intellectual disability. For persons qualifying due to intellectual disability
only, a recent medical summary report may be provided, if available.
2. A psychological report that includes a comprehensive assessment of intellectual
functioning with the reporting of intelligence testing scores (including subscale,
index, and full-scale scores) and a standardized assessment of adaptive behavior
with reporting of composite, domain, and sub-domain/skill area summary scores.
3. A social/developmental history, psychosocial report, or other background report that
provides evidence that the person met the criteria before age 22 years.
Social/developmental information is still needed if the person is a child or
adolescent.
4. A full report or other summaries of all contemporary diagnoses or classifications of
health, including physical, developmental, or psychiatric conditions that are relevant
to the determination of eligibility.
5. In the case of an autism spectrum disorder (ASD), a report(s) constituting a
comprehensive evaluation for the ASD diagnosis is required.
In some cases, the DDRFO staff may not be able to determine whether someone
meets the eligibility requirements based on the reports and information that is
provided. In those cases, the DDRFO may request further information or different
reports, and may either recommend where these tests be conducted or arrange for
them to be conducted.
D. Practitioners Qualified to Conduct Standardized Testing
OPWDD relies upon valid results from standardized testing when making an eligibility
determination, therefore, such testing must be performed by a qualified practitioner.
Professionals who are “qualified practitioners” and who may administer and interpret
standardized measures of intelligence and adaptive behavior are defined as:
Persons with directly relevant Master’s degrees, or doctoral level
education in Psychology, with training and supervised experience in
the use and interpretation of such measures consistent with the
recommendations contained in the respective test manuals for measures
and with the requirements of the most current edition of the
AERA/APA/NCME (2014) Standards for Educational and
Psychological Testing, for the use and interpretation of individual test
results.
Qualified practitioners must practice in accordance with current evidence-based practices
OPWDD Guidance: Eligibility Guidelines Page 6 of 27
and clinical practice guidelines established for their profession. Practitioners are trained
to appraise information obtained using psychometric and other measures. They are
expected to be cognizant of such considerations as:
• The standard error of measurement and standard error of the mean; and
• Factors that increase or decrease the validity and reliability of test and assessment
results; and
• The importance of integrating and interpreting test results in the context of
previously obtained results, clinical history, and collateral information.
These factors must be considered when deciding whether eligibility criteria for intellectual
or adaptive behavioral functioning are met.
Qualified practitioners trained and experienced in sub-specialty areas, and whose scope
of practice includes formulating a diagnostic impression, are encouraged to perform or
coordinate differential diagnostic assessments (i.e., differentiating one disorder from
another that may have some similar presenting characteristics), rather than exclusively
ruling in or ruling out single specific conditions. Such assessments may include testing
limits, identifying and evaluating significant or characteristic discrepancies between skill
and performance measures, and utilizing multiple clinical and testing measures to
evaluate the presence of a concurrent or pre-existing disorder.
Reports prepared by Master’s-level unlicensed or uncertified examiners who are qualified
practitioners, which include diagnostic statements, must be supervised and co-signed by
a licensed practitioner qualified to assess and diagnose the relevant condition, and who
has been involved in the assessment process. All practitioners may only perform work that
is within their scope of practice and based upon their education and training.
In cases where no information is available regarding age of onset of disability during the
developmental period (e.g., for someone now in mid-adulthood), DDRFOs are advised to
rely on the informed clinical judgment of appropriately licensed professionals. These
judgments should be based on the best available and obtainable information.
Efforts must be made to obtain historical records (such as school, medical, psychiatric,
mental health/psychological, or other disability records), as opposed to presuming that
such records no longer exist. DDRFOs may require documentation of efforts to obtain
records. In cases where records cannot be obtained, other sources of information (such
as retrospective as well as current collateral information from relatives, friends, neighbors,
etc.) should be considered. In addition, the nature of the person’s disability, social history,
culture, background, and primary or preferred language should be considered when
determining whether the person meets the eligibility criteria.
E. Need to Use Prevailing Diagnostic Nomenclatures and Accepted Diagnostic
Practices
It is expected that practitioners will designate diagnostic classifications that
correspond to the prevailing clinical nomenclatures at the time of the assessment
(e.g., the current edition of the International Statistical Classification of Diseases
established by the World Health Organization [ICD, WHO]; the current edition of the
Diagnostic and Statistical Manual of Mental Disorders [DSM, American Psychiatric
OPWDD Guidance: Eligibility Guidelines Page 7 of 27
Association]).
For example, the diagnosis of intellectual disability cannot be rendered, according to the
present diagnostic criteria, without a determination of concurrent adaptive or functional
limitations and age of onset, as well as significant deficits in general intellectual
functioning.
Persons seeking OPWDD eligibility must meet the diagnostic criteria of the qualifying
condition. The determination of the presence of these disorders should follow accepted
clinical practice guidelines. A diagnosis may not be rendered based solely on the results
obtained from screening instruments or the results of other, single evaluative measures
or processes in isolation. For example, a diagnosis of autism spectrum disorder (ASD)
requires a comprehensive evaluation that includes a careful review and description of
early development and the emergence of ASD symptoms, current symptoms that are
consistent with diagnostic criteria, personal interview/observation, collateral information
from a standardized diagnostic measure, and careful differentiation from other
developmental or psychiatric disorders. The report should include both the scores from
standardized measures, as well as detailed description of the person.
OPWDD will scrutinize diagnostic statements that are not supported by corresponding and
appropriately documented clinical and psychometric assessment findings. This scrutiny
will occur regardless of whether eligibility is sought based on the presence of intellectual
disability or another qualifying condition.
OPWDD Guidance: Eligibility Guidelines Page 8 of 27
SECTION III: FUNCTIONAL LIMITATIONS, INTELLECTUAL AND
ADAPTIVE FUNCTIONING AND SUBSTANTIAL HANDICAP
A. Functional Limitations
Functional limitations are generally considered to constitute a substantial handicap when
they prohibit a person from being able to function independently in daily life or when
the development of functional skills related to daily living are significantly below
expectations given the person’s age. The clinical determination of when a condition
constitutes a substantial handicap is complex and involves numerous factors.
Functional limitations constituting a substantial handicap are herein defined as:
significant limitations in adaptive functioning that are determined from the findings of an
assessment by using a nationally normed and validated, comprehensive, individual
measure of adaptive behavior, administered and interpreted by a qualified practitioner
following appropriate administration guidelines.
B. Assessing Intellectual Functioning and Adaptive Functioning
Significant limitations in general intellectual functioning and limitations in adaptive
functioning are determined using different kinds of tests or measures.
Significant limitations in general intellectual functioning are determined from the
findings of one or more assessments by using a nationally normed and validated,
comprehensive, individual measure of intelligence that is administered in a standardized
format, in its entirety in accordance with standardization procedures, and interpreted by
a qualified practitioner. In exceptional circumstances, non-standardized testing formats
may be used, if this is documented and an appropriate rationale and justification is clearly
stated. For example, directions for nonverbal subtests in a Wechsler IQ test may be
translated into a non-English speaking person’s primary language (see Appropriate
Standardized Assessment Measures).
Significant limitations in adaptive functioning are determined from the findings of an
assessment by using a nationally normed and validated, comprehensive, individual
measure of adaptive behavior. Such functional limitations may not be presumed solely
based on low scores on a comprehensive, individual measure of intellectual functioning.
Similarly, the presence of significant limitations in adaptive behavior does not constitute
a basis upon which presence of significantly sub-average intellectual functioning may be
presumed.
Onset of significant limitations in adaptive behavior constituting substantial handicap,
as defined in this document, must occur before the person attains age 22, to satisfy the
requirements of MHL 1.03(22)(b). Onset must be verified as the presence of significant
limitations in adaptive behavior prior to age 22.
OPWDD Guidance: Eligibility Guidelines Page 9 of 27
C. Using Scores on Adaptive Behavior Measures to Establish Necessary Functional
Limitations
Functional limitations can be evaluated using one of the following three sets of criteria to
establish the presence of a substantial handicap.
1. For adaptive behavior measures that provide an overall composite score (e.g.,
ABAS-3, or VABS-3), the criterion of significance for defining substantial handicap
is an overall composite score that is 2.0 or more standard deviations below the
mean for the appropriate norming sample.
2. For adaptive behavior measures that provide composite and domain scores (e.g.
in the VABS-3 or ABAS-3), an alternate criterion of significance is that the majority
of these domain scores lie 2.0 or more standard deviations below the mean for the
appropriate norming sample (even if the composite score is not 2 or more standard
deviations below the mean).
3. For adaptive behavior measures that provide composite, domain scores, and
specific skill area/subdomain scores (e.g., ABAS-3, or VABS-3), a third criterion
of significance is that the majority of adaptive skill areas/subdomain scores lie at
2.0 or more standard deviations below the mean for the appropriate norming
sample (even if the composite and domain scores are not 2 or more standard
deviations below the mean).
Adaptive behavior measures that do not provide an overall composite score, multiple
domain scores, or skill area scores, as described above, will not be considered for
determining the presence of functional limitations constituting a substantial handicap.
For adaptive behavior measures that permit assessment of both adaptive and maladaptive
behavior, the presence of clinically significant maladaptive behaviors in the absence of
significant limitations in adaptive behavior, as defined above, does not meet the criterion
of significant limitations in adaptive functioning.
Using information gleaned from the review of records and findings from the use of
standardized and normed assessments, it must be determined that significant functional
limitations are not:
• due to a current acute or severe phase of a psychiatric disorder; or
• a consequence of, or better accounted for by, the person’s psychiatric disorder,
substance use, or substance-related disorders.
When a psychiatric or substance-related disorder is present, clinicians must consider
factors such as premorbid level of adaptive functioning and level of functioning at times
when the psychiatric/substance abuse symptoms are in remission to help clarify the
relative impact of the comorbid conditions on the person’s functional limitations.
D. Substantial Functional Limitations and Qualifying Conditions
The determination should also be made that significant functional limitations are
associated with, attendant to, or result from, a qualifying condition(s). For the purposes of
OPWDD Guidance: Eligibility Guidelines Page 10 of 27
eligibility determinations, developmental disorders/qualifying conditions are defined as
conditions that meet the criteria set forth in the Mental Hygiene Law for developmental
disability.
Qualifying conditions other than those enumerated in MHL 1.03(22)(a)(1) must be similar
or closely related to intellectual disability, including that they must cause or result from
injury to, dysfunction, disorder, or impairment of the Central Nervous System, i.e., the
brain or spinal cord. Conditions similar or related to intellectual disability in their effects
(MHL 1.03(22)(a)(2)) include the presence of a neurological impairment or degeneration
because of a disease or disorder affecting the central nervous system. To be OPWDD
eligible, the person must have a qualifying condition and significant impairment in adaptive
and daily functioning that is directly attributed to the qualifying condition.
E. Appropriate Standardized Assessment Measures
Standardized assessment measures that are appropriate as sources of information to be
used in eligibility determinations have several key characteristics:
• Their reliability and validity are suitably verified by peer-reviewed research.
• Their reliability, validity, indicated uses, and performance parameters are
adequately presented in the relevant technical manuals and test manuals.
• They are normed or criterion-referenced, and their performance has been
ascertained on a representative, suitably structured population sample of sufficient
size to permit stability of scores and score patterns.
• They are normed on suitably sized and reasonably contemporary representative
population samples (i.e., the norms are not outdated).
• They are standardized in their mode and parameters (process) of administration
and are administered in conformance with those parameters.
• They are suitably structured and comprehensive, or targeted for their respective
purposes, such as assessing intellectual, behavioral, social and personality, or
academic functioning.
Updated or current evaluations of intellectual functioning and adaptive behavior
must be based upon the most recent version of the instrument used. When a new
version of an existing test becomes available, older versions of that test must not be
accepted if they were administered more than 12 months after the publication of the
newest version.
Examples of appropriate intellectual measures include the current versions of:
• The Kaufman Assessment series;
• The Leiter International Performance Scale;
• The Stanford-Binet Intelligence Scales;
• The Wechsler series of Intelligence Scales;
• The Woodcock-Johnson Tests of Cognitive Abilities; and
OPWDD Guidance: Eligibility Guidelines Page 11 of 27
• Other intelligence tests may be acceptable if they are comprehensive, structured,
standardized, and have up-to-date general population norms.
Brief or partial administration of comprehensive intellectual measures may be utilized only
in circumstances where standardized administration is impossible due to sensory
disability or profound and generalized impairment of activity, and in conformance with the
most current edition of the AERA/APA/NCME standards for use and interpretation of
individual test results. If a person is determined to have such significant cognitive
limitations that they are unable to understand or respond to the administration of
comprehensive standardized tests, a clinician may use alternate assessment
techniques or measures to document functioning levels and help estimate the
severity of an obvious developmental disability. A description of the circumstances and
rationale for such an adaptation must be included in the report.
Findings from abbreviated measures of intelligence (e.g., WASI or KBIT) or adaptive
behavior scales will not substitute for a comprehensive assessment and will not solely be
considered when determining eligibility.
Tests or instruments assessing nonverbal intelligence (e.g., the Leiter Scale, the
Universal Nonverbal Intelligence Test, the Comprehensive Test of Nonverbal
Intelligence), in combination with the Performance items of a comprehensive IQ test (with
directions translated into the examinee's native language or means of communication),
will be considered for people who are not proficient with the English language, who have
hearing impairment, or who do not communicate through the use of oral language.
In all other cases, comprehensive intellectual assessment measures standardized in
English that have been administered by translation into another language are not
acceptable for eligibility determination purposes.
Examples of standardized measures that are not considered to be comprehensive in
nature, and are not accepted include, but are not limited to:
• The Peabody Picture Vocabulary Test;
• Slosson Intelligence Test
• The Reynolds Intellectual Assessment Scales (RIAS); and
• Testing formats that project non-administered subtest scores from those that are
administered.
Examples of appropriate comprehensive measures of adaptive behavior include
current versions of:
• The Adaptive Behavior Assessment System (ABAS);
• The Vineland Adaptive Behavior Scales (Vineland or VABS);
• The Scales of Independent Behavior-R (Motor Skills Domain only); or
• Other adaptive behavior measures are acceptable if they are comprehensive,
structured, standardized, and have up-to-date general population norms.
Adaptive behavior measures must reflect the person’s typical or actual behavior, not their
best or potential behavior under optimal circumstances. In general, an person’s self-report
should not be the only source of information gathered for the assessment, particularly
OPWDD Guidance: Eligibility Guidelines Page 12 of 27
when the person has a condition(s) that may affect their current cognitive functioning or
ability to provide a valid or reliable report about his/her abilities.
As with all testing, adaptive behavior measures should be administered, scored and
interpreted by professionals trained on the use and interpretation of the measure. Such
professionals must meet the education and training requirements established for each
scale in the measure’s respective test manual(s). For eligibility purposes, an interpretive
report, completed by a qualified professional, must be submitted with all adaptive behavior
assessments.
The submission of a computer-generated report based on the entry of raw scores will not
be considered for the purposes of determining eligibility as such reports are not
individualized. Any interpretation of the findings is not inclusive of the totality of information
obtained throughout the assessment process. Therefore, while these results can be used
by clinicians, clinicians must create their own reports.
F. Establishing Substantial Functional Limitations for Provisionally Eligible Children
There are circumstances when the ability to determine eligibility for services on a
provisional or conditional basis has enabled OPWDD to provide supports and services to
young children whose condition and/or functioning may improve significantly over time,
because of specialty treatments and services. It has enabled parents of these children to
receive assistance in obtaining environmental modifications, assistive equipment, and
access to diagnostic assessment and treatment resources. During the period of
provisional eligibility, cognitive and functional capacities may be developed or maximized
to the point that the developmental disorder or apparent similar condition is no longer a
source of substantial handicap.
Early identification and intervention can be critical to achieving the best outcomes for youth
with Intellectual or Developmental Disability (I/DD). However, establishing a definitive
diagnosis, prognosis, and likelihood of future level of impairment may be challenging due
to individual differences in developmental trajectories and response to available services.
Provisional eligibility runs from a child’s birth through age 7. Provisional eligibility extends
the available time to complete school-based assessments and affords OPWDD time to
review and consider whether the person meets the eligibility requirements. On the child’s
8
th
birthday, they must meet the full eligibility criteria to continue receiving OPWDD
supports and services.
DDRFOs may grant provisional eligibility for children birth through age 7. However, if
a child meets the full eligibility criteria before age 8, they may be granted full
eligibility.
Psychometric assessment is the primary method used by OPWDD in establishing the
presence of marked limitation confirming substantial functional limitations. Qualified
clinicians must be knowledgeable in the use of differential diagnostic measures applicable
within the full range of referral ages.
For children from birth through age 7, and consistent with Part 200.1(mm)(1) of the NYS
Education Law, substantial functional limitation associated with global or specific
OPWDD Guidance: Eligibility Guidelines Page 13 of 27
developmental delays is defined as:
• A 12-month delay in one or more functional area(s); or
• A 33% delay in one functional area, or a 25% delay in each of two functional areas;
or
• If appropriate standardized instruments are individually administered in the
evaluation process, a score of 2.0 standard deviations below the mean in one
functional area, or a score of 1.5 standard deviations below the mean in each of
two functional areas.
For children from birth though 7 years, psychometric and developmental measures that
derive a developmental quotient or mental age may be accepted as suitable and
appropriate means to confirm functional or intellectual delays or disability.
In addition to adaptive behavior scales suited for the assessment of infants, toddlers,
preschoolers, or children entering primary school, psychometric instruments that may
provide appropriate and needed information include current versions of the:
• Battelle Developmental Inventory (BDI);
• Bayley Scales of Infant Development;
• Differential Ability Scales (DAS);
• Infant-Toddler Developmental Assessment (IDA);
• Kaufman Assessment Battery for Children;
• Stanford Binet Intelligence Scales;
• Wechsler series of intelligence Scales; or
• Woodcock-Johnson Tests of Cognitive Ability.
For children aged 8 years and older, the criteria to determine whether a person meets
eligibility requirements for OPWDD services shall be the same as those set forth
elsewhere in this document. That is, it is necessary to confirm a specific qualifying
diagnosis that results in a substantial handicap originating in the developmental period,
with an expectation of indefinite continuation.
OPWDD Guidance: Eligibility Guidelines Page 14 of 27
SECTION IV: DDRFO REVIEW PROCESS
A. Established Review Procedures
OPWDD has established assessment and review procedures to determine the presence of
a developmental disability and the resulting substantial handicap. These procedures are
designed to provide equitable assessments and fair and objective reviews of cases. This
process is known as the three-step process or eligibility determination process, outlined
below.
At any point in the eligibility determination process, designated DDRFO staff may request
additional information or further assessment of the person to determine eligibility.
Staff may also request further assessment by an independent, qualified practitioner, or may
conduct assessments of the person to assure accuracy within the process. Such requests
for additional information will be made to the person(s) or agency who are seeking services.
i. Eligibility Application
To have eligibility established with OPWDD, the person must begin the process of
applying for eligibility. This process includes:
a) The person contacting the Front Door at the DDRFO to show their interest in
getting OPWDD services.
b) The Front Door connects the person with a Care Coordination Organization
(CCO).
c) The CCO works with the person to gather all documents required for an
eligibility determination. This includes:
i) Required documents:
- Cognitive testing;
- Adaptive assessments;
- Medical documentation;
- Physical or Medical summary (general medical report completed in
the last 12 months);
- Social/developmental history, psychosocial report or other report
that shows that the person became disabled before age 22 (unless
contained in other reports);
- Social evaluation (completed in the last 12 months); and
ii) Other helpful documents, as applicable:
- Individualized Education Plan (IEP), 504 Plan, and other
educational documents; and
- Mental health evaluations and records.
d) Once the documents have been gathered, the CCO uploads the documents
and a Transmittal Form to CHOICES. Note, an application must have a
Transmittal Form.
e) After uploading the information to CHOICES, the CCO sends an e-mail to the
CCO Mailbox informing OPWDD that the information is ready for OPWDD
review.
OPWDD will only review formal applications for eligibility determination. A formal
OPWDD Guidance: Eligibility Guidelines Page 15 of 27
application for eligibility is defined as: having all required documents and the
transmittal form uploaded to CHOICES and sending an e-mail to the CCO Mailbox
informing OPWDD of the CHOICES upload. Once the application is submitted,
OPWDD reviews and determines whether the person is eligible for OPWDD services
based on the criteria outlined in MHL § 1.03(22) and 14 NYCRR §§ 629.1 and 630.5-
10.3. For more information on eligibility applications, see Application Checklist for
Determination of OPWDD Eligibility (page 24).
Other Considerations for OPWDD Eligibility Applications:
An OPWDD Transmittal Form must accompany all requests submitted to the DDRFO
for eligibility determinations. The Transmittal Form includes the name of the person,
their representative (if applicable), and relevant contact information. Documentation
of the person’s developmental disability must also be included as part of the eligibility
request. The Transmittal form can be found on the OPWDD website at
https://opwdd.ny.gov.
For those applicants lacking complete documentation of a condition that may
constitute a developmental disability or documentation that provides information
related to a substantial handicap as described in these guidelines, the designated
DDRFO intake personnel will request the referral source to provide the needed
additional documentation.
Upon the receipt of complete documentation, the DDRFO will make an eligibility
determination in a timely manner (see description of each step for details).
ii. 1
st
Step Review
DDRFO staff review the eligibility request for completeness and share information
with staff designated by the DDRFO Director as necessary. After this review, the
following outcomes are possible:
• Eligibility or Provisional Eligibility has been determined; or
• The documentation accompanying the request is incomplete and additional
documentation is required; or
• The request has been forwarded for a 2
nd
Step Review.
If the individual is determined Eligible or Provisionally Eligible, and the 1
st
Step
Reviewer is not a Licensed Psychologist or Licensed Clinical Social Worker, the 1
st
Step determination must be reviewed for accuracy by a Licensed Psychologist or
Licensed Clinical Social Worker prior to a determination letter being issued.
Once the complete referral documentation packet is received, the 1st Step decision
should be issued by the DDRFO within 30 days.
When it cannot be confirmed that the person meets OPWDD eligibility criteria, their
eligibility packet must be forwarded for a 2nd Step Review.
OPWDD Guidance: Eligibility Guidelines Page 16 of 27
iii. 2
nd
Step Review
Each Regional DDRFO has established a 2
nd
Step Eligibility Review Committee. This
team includes a licensed psychologist and other clinicians as designated by the
Regional DDRFO Director. When appropriate, the 2
nd
Step Committee should also
include input from a licensed physician, a physician's assistant, or a nurse
practitioner.
The 2
nd
Step Eligibility Committee will conduct a review of the eligibility materials
forwarded by the 1
st
Step Review, including any additional documentation that was
provided. If the 2
nd
Step Committee requires additional medical information,
psychological test results, or historical documentation, the person who submitted the
request for services is notified in writing about the type of information needed and the
date by which such information must be submitted to the DDRFO. Once a complete
referral packet (including any newly requested information) is received, the DDRFO
should make an eligibility determination within 30 days.
Following the 2
nd
Step Review, the DDRFO provides the person with written
notification of the committee’s determination. If the person is found ineligible for
OPWDD services, because they do not have a developmental disability or qualifying
condition [as defined by Mental Hygiene Law, Section 1.03(22)], the DDRFO must
provide them with a summary list of materials or reports that were reviewed and
considered and the reasons for the denial. In addition, the letter shall offer the person
and their representative, the opportunity to:
• Meet (face-to-face) with the DDRFO staff to discuss the determination and
documentation reviewed;
• Request a 3
rd
Step Review; and
• Request a Medicaid Fair Hearing if Medicaid-funded services are sought.
A Notice of Decision (NOD) informing the person of their right to request a Medicaid
Fair Hearing is sent only when the Transmittal Form indicates that the person has
identified an interest in receiving Medicaid-funded OPWDD services. If the person
has not indicated an interest in receiving Medicaid-funded services, a Fair Hearing is
not offered, and the decision of the DDRFO is final.
The individual may choose one, two, or all three of the above options. If a Fair
Hearing is requested, a 3
rd
Step Review will be initiated automatically.
iv. 3
rd
Step Review
3
rd
Step Reviews are coordinated by OPWDD Central Office. Committee members
include licensed practitioners who were not directly involved in the determinations
made at the 1
st
and 2
nd
Step Reviews. The Committee reviews the submitted eligibility
request and any corresponding documentation provided by, or on behalf of, the
person. The Committee forwards its recommendations to the DDRFO 2
nd
Step
Eligibility Review Coordinator and the Director of the DDRFO. The DDRFO Director
or designated staff person(s) considers the 3
rd
Step recommendations and informs
the person of any change in the DDRFO’s determination. 3
rd
Step reviews will be
completed upon request or, with sufficient notice, prior to any Medicaid Fair Hearing
OPWDD Guidance: Eligibility Guidelines Page 17 of 27
date.
Upon receipt of all of the required documentation from the DDRFO, Central Office will
have 30 days to determine eligibility and notify the DDRFO of its finding. The DDRFO
will then have 10 days to notify the referring party of any changes in the DDRFO’s
determination.
v. Provisional Eligibility for Children Through Age 7
A child through age 7 (i.e., prior to child’s 8
th
birthday) may be found to be provisionally
eligible following a First, Second, or Third Step review when the available evidence
indicates the presence of developmental disability but is insufficient for a full
determination of eligibility. An eligibility redetermination shall be required, as
specified in the initial or subsequent determinations of provisional eligibility
but must be completed at least once prior to the child’s 8
th
birthday. Children
with provisional eligibility who have reached their 7
th
birthday will not be
authorized to receive additional services (e.g., an increase in service hours for
services approved before their 7
th
birthday; or new services that were not
approved before their 7
th
birthday), except in extraordinary circumstances and
upon the approval of the Commissioner.
It is expected that provisional eligibility will be established exclusively in those
instances where infants and young children between birth and seven years of age
manifest substantial delays, with or without specific congenital or acquired conditions
that have a high probability of resulting in developmental disability if services are not
provided. Most often, due to the cycle of assessment and review practices in the
educational sector, and other factors relevant to informed prognostic judgments,
reviews of Provisional Eligibility determinations will be conducted between the ages
of 6 and up to 8 years; however, interim reviews may be completed at earlier ages if
clinically indicated or requested by the DDRFO. Review of a Provisional Eligibility
determination may result in:
• Renewal of Provisional Eligibility (this option is not available once the child
reaches their 8
th
birthday);
• Determination of full eligibility; or
• Determination of ineligibility.
vi. Maintaining Eligibility Records
All documentation used for eligibility determinations will become a permanent part of
the clinical record for each individual and must be maintained as such by the DDRFO.
It is also recommended that the individual or referring agency retain such information
as well.
B. Redeterminations of Eligibility
OPWDD may review and consider an individual’s eligibility status, except for Willowbrook
OPWDD Guidance: Eligibility Guidelines Page 18 of 27
Class members, at any time.
1
However, there are some situations where eligibility
redeterminations are generally done, including:
• Before expiration of provisional eligibility status or at age eight for individuals who
remain in provisional eligibility status but who have not submitted timely updated
information by their 8
th
birthday (e.g., by their 7
th
birthday);
• New information is presented that raises a question regarding eligibility;
• There has been a significant break in service/s and the individual’s ability to live
independently without significant supports during that time casts doubt on the degree
of the individual’s adaptive deficits and continuing need for services;
• An individual resides in a Nursing Facility, with no OPWDD eligibility determination
since 1/1/2007; and
• Limited Service: new or additional services are requested by individuals whose
eligibility status was not confirmed by a prior full eligibility review.
i. Provisional Eligibility
Eligibility for children who are first determined provisionally eligible for services must
be reviewed again by a DDRFO prior to the child’s eighth birthday. The DDRFO
should notify the family, or other authorized representative, of the need for updated
documentation for this review about twelve months prior to the individual’s provisional
eligibility expiration date. Updated clinical information should be provided to the
DDRFO by the child’s 7
th
birthday so their provisional eligibility can be reviewed. If
updated documentation is not timely provided, the individual’s eligibility determination
may be delayed, potentially resulting in a lapse in services. Provisional eligibility
expires as of the child’s eighth birthday and providers must not bill for services
provided after that date unless updated information has been submitted and is under
review or a written notice of eligibility termination has been issued by the DDRFO and
continuation of aid has been requested.
ii. New Information
In certain circumstances, new information is made available to the DDRFO or to the
agency providing services. The eligibility of an individual receiving Medicaid services
is reviewed when information is made available that indicates that (a) the original
referral record was incomplete; (b) the original record does not accurately represent
the individual’s current status and eligibility; or (c) the original determination was
made in error.
As with the redetermination process described above, the DDRFO will review current
assessments and evaluations regarding an individual’s diagnoses and level of
adaptive functioning, and all other available records. When the individual does not
meet the eligibility criteria, a face-to-face meeting and 3
rd
Step review are offered
before a Notice of Decision is issued to discontinue Medicaid-funded services and
notification of the individual’s right to a Fair Hearing.
1
Willowbrook Class members will remain eligible for OPWDD services, and their status will not be re-
determined, even if their circumstances change over time.
OPWDD Guidance: Eligibility Guidelines Page 19 of 27
iii. Significant Break in Service
This circumstance may occur when an individual previously enrolled in an OPWDD
program has not received available services for one year or more (i.e., there is a
significant break in service), and the individual’s ability to live independently without
significant supports during that time casts doubt on the degree of the individual’s
adaptive deficits and continuing need for services. Consistent lack of access to a
service that is being sought during a period does not constitute a ‘break in service.’
Additionally, a break in service associated with a medically necessary placement in a
skilled nursing or long-term rehabilitation facility should be expected to be substantially
longer (up to a three-year period) before an eligibility re-review may be considered.
Exceptions to the rule apply to residents of nursing facilities. If the person is
currently residing in an ICF or resided in an ICF immediately prior to hospitalization or
nursing facility (NF) admission, or is a Willowbrook Class member, eligibility need not
be reviewed, and the person can be considered eligible for OPWDD services and for
new OPWDD services. Likewise, if the person is currently enrolled in HCBS, or was
enrolled immediately prior to hospitalization or NF admission, eligibility need not be
reviewed and the person can be considered eligible for new OPWDD services.
iv. Eligibility Status and Limited Services/Service Requests
Some people who may not have had an initial full eligibility review in the past may be
required to have a full, formal review of documentation to justify current eligibility when
they request certain services. The re-determination requirement is not automatic; it
depends on the level of a person’s current status and services.
For example, an individual who currently receives HCBS waiver service(s) would not
have eligibility re-determined if the person requests a new service or changes a level
of service. Similarly, those whose disability has been well-documented through
residence in an ICF setting would not have eligibility re-determined before transfer to
another residence, or enrollment in the HCBS waiver. However, an individual who has
not previously had a full eligibility review who receives Care Management only, or other
limited services (Family Support Services and/or Article 16 clinic services), would have
to initiate and complete the full eligibility review process if enrollment in HCBS is
requested.
In general, certain individuals who receive limited services and have had no prior
formal eligibility review in the past would continue to receive only currently utilized
services. If additional services are requested/needed, the individual would have a
formal eligibility review to determine whether they have a qualifying developmental
disability or condition. Without this review, individuals are prevented from receiving
additional services until their status is changed.
In accordance with the guidance above, if individuals require an eligibility
review/determination before additional services can be approved, they should be
advised of the risk of being terminated from their existing services should they be found
not to meet DD criteria because of the eligibility review.
OPWDD Guidance: Eligibility Guidelines Page 20 of 27
This general rule regarding service status and eligibility determination applies to
residents of nursing facilities, whether they currently receive OPWDD services,
formerly received OPWDD services, or are a resident in a nursing home who is
referred for eligibility review. If an individual is being considered for NF placement, or
is already admitted to an NF and requires a Preadmission Screening and Resident
Review (PASRR) Level II assessment, their eligibility status must be confirmed. If the
person is already known to the OPWDD system, but has not had an eligibility
review/determination, the general rule is that DD eligibility must be established before
the person can be considered for any new OPWDD services. The person should be
referred to the 3-step eligibility process, subject to the exceptions noted.
OPWDD Guidance: Eligibility Guidelines Page 21 of 27
SECTION V: FACTORS THAT PROMPT SECOND STEP REVIEW
Each Regional DDRFO has established a 2
nd
Step Eligibility Review Committee that conducts a
review of the eligibility materials forwarded by the 1
st
Step Review, including any additional
documentation that was provided. Certain factors are likely to prompt the need for 2
nd
Step review
of eligibility determinations. Eight examples follow:
1. Requests for eligibility determinations submitted by a referral source that has previously
submitted inaccurate or incomplete information regarding the person and their related
diagnoses, details of onset, anticipated continuation of disability, or substantiality of
handicap.
2. Requests for eligibility determinations for a person with a sensory impairment (e.g.,
profound loss of vision or hearing).
3. Requests for eligibility determinations for a person with exceptional needs (for example:
significant sensory impairment, English is not the individual’s primary language, or
younger than age 5) that have not been evaluated using the most appropriate instruments
to ascertain the nature of the disability condition or presence of substantial handicap.
4. Requests for eligibility determinations for people diagnosed with a disability condition
which is associated with idiosyncratic or greatly varying substantiality, of handicap or
functional limitations, and for which the severity and breadth of functional limitations
consistent with substantial handicap are not adequately assessed and documented. This
would include such conditions as: Autism Spectrum Disorder, Traumatic Brain Injury (TBI)
and Epilepsy.
5. Requests for eligibility determinations for a person with past or present involvement in
correctional or criminal justice services (CJS) and incomplete documentation of qualifying
disability, onset, expectations of indefinite continuation, and/or substantiality of handicap.
In instances where correctional or CJS involvement is a concern, reviewers may wish to
investigate the possibility of:
• Malingering;
• Assessment under inappropriate conditions;
• Functional illiteracy that decreases test scores;
• The inconsistency with which adaptive behavior may be assessed or evident in
correctional and non-correctional environments (e.g., skill vs. performance
opportunity issues); or
• Neurological injury sustained after the person reaches age 22.
6. Requests for eligibility determinations for a person with incomplete documentation of
disability, onset, expectations of indefinite continuation, or substantiality of handicap, and
past or present involvement in alcohol or drug abuse or dependence.
7. Requests for eligibility determinations for a person with past or present psychiatric
disability. Examples include:
• When documentation of a developmental disability before or concurrent with the
psychiatric disability, and occurring prior to age 22, is unavailable;
OPWDD Guidance: Eligibility Guidelines Page 22 of 27
• When intellectual and functional assessment findings consistent with presence of
a developmental disability are limited to results obtained at times when the impact
of psychiatric disability on the person's functioning is especially marked or not
described (e.g., during periods of psychiatric instability or psychiatric stability is not
specified); or
• To confirm that functional limitations resulting in substantial handicap are
associated with a condition recognized in MHL 1.03(22) as a developmental
disability, it is crucial to ascertain whether the developmental condition and
functional limitations pre-existed the onset of the psychiatric disability, or whether
a pre-existing developmental condition may have been a risk factor for both onset
of the psychiatric disability and increased severity of limitations in adaptive
behavior.
8. When a psychiatric disability and a developmental disability are both present, eligibility will
be based on the presence of a developmental disability, as defined herein, regardless of
whether the psychiatric disability or developmental disability is "primary." Such individuals
may be dually eligible, in that they are eligible for services from both the mental health and
developmental disabilities services sectors. Some of these individuals may require
stabilization services through the mental health sector, and further assessment prior to
participation in developmental disabilities services.
OPWDD Guidance: Eligibility Guidelines Page 23 of 27
SECTION VI: REFERENCES
American Educational Research Association, American Psychological Association, & National
Council on Measurement in Education. (2014). Standards for educational and
psychological testing, Washington, DC: AERA.
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders,
5
th
edition Text Revision., Washington, DC: Author.
Schalock, R. L., et al. (2021). Intellectual Disability : Definition, Classification, and Systems of
Supports (12th Edition). Washington, DC : American Association on Intellectual and
Developmental Disabilities.
OPWDD Guidance: Eligibility Guidelines Page 24 of 27
Appendix A: Application Checklist for Determination of OPWDD
Eligibility
Application Checklist for Determination of OPWDD Eligibility
Name: ____________________________ Date of Birth: ______________
Language: _____________________________ Age*: ________________
What do you believe the qualifying diagnosis** is?
___________________________________________________________
* AGE: Age is important in determining OPWDD eligibility. If the person is 7 years of
younger, they might not have a qualifying diagnosis yet. In this case, OPWDD may
consider granting them provisional eligibility when considering all other information.
**QUALIFYING DIAGNOSES: These include Intellectual Disability (ID), Cerebral
Palsy (CP), Epilepsy/seizure disorder, Autism Spectrum Disorder (ASD), Familial
Dysautonomia (a rare genetic disorder), Prader-Willi Syndrome, and other
Neurological Impairments (injury, malformation, or disease of the brain and/or spinal
cord) that is expected to continue indefinitely.
Process for Eligibility Document Submission to OPWDD
Person
contacts
the Front
Door for
OPWDD
Eligibiilty
OPWDD
connects
the person
with a CCO
CCO works
with the
person to
gather all
required
documents
(see below)
CCO
submits all
required
documents
and the
Transmittal
Form to
CHOICES
CCO sends
e-mail to
the CCO
Mailbox
that the
documents
have been
uploaded
to CHOICES
OPWDD
begins
reviewing
the
Eligibilty
Application
OPWDD Guidance: Eligibility Guidelines Page 25 of 27
Eligibility Documents
Required Documents:
_____ Cognitive Testing (All available)
_____ Adaptive Assessments (All available)
_____ Medical Documentation (If the qualifying diagnosis is suspected to be something other than an
intellectual disability, you must provide documentation to support the diagnosis at the time it was diagnosed)
_____ OPWDD Transmittal Form (Must be submitted with the upload of required documents to
CHOICES. Additional Transmittal Forms must also be uploaded to CHOICES if the person’s demographic
information changes during the eligibility determination process)
_____ Physical or Medical Summary (General medical report completed within the past 12 months)
_____ Social/developmental history, psychosocial report or other report that
shows that the person became disabled before age 22 (unless contained in other
reports)
.
_____ Social evaluation (https://opwdd.ny.gov/adm-2020-04-social-evaluation-
requirements-initial-level-care-eligibility-0)(Completed within the past 12 months)
Other helpful documentation, as applicable:
_____ IEP or 504 Accommodation Plan and/or other school records (Most recent
IEP/504. Please also send us all psychoeducational reports referenced on the Plan)
_____ Mental Health Evaluations & Records, if applicable (Intake, Discharge, Treatment
Plans – no progress notes please)
Next Steps:
• Upload required documents to CHOICES.
• E-mail the CCO Mailbox and let OPWDD know that the documents are in
CHOICES. The documents, uploaded information to CHOICES, and e-mail are the
person’s application for OPWDD eligibility.
Please see attached or reverse for descriptions of the above.
OPWDD Guidance: Eligibility Guidelines Page 26 of 27
OPWDD Eligibility Documentation Additional Information
TRANSMITTAL FORM
• Transmittal Form: See attached. Transmittal forms must be uploaded to CHOICES along
with all required documentation. Instructions on how to complete the form are on the back
of the form.
PSYCHOLOGICAL TESTING
(See the attached “Important Facts” sheet for acceptable measures)
• IQ (Cognitive) Testing: All current and available evaluations which include an
assessment of intellectual functioning (“IQ test”). This report must include all summary
scores from the assessment (e.g., Full Scale, Index, Part and Subtest scores).
• Adaptive Behavior Assessment – This is an interview or form completed by someone
familiar with the person, in order to provide information about their daily living skills and
functioning. As with IQ testing, the report should include all scale and summary scores and
a narrative report written by the clinician. Computer generated reports alone are not
acceptable.
MEDICAL REPORTS AND SPECIALTY ASSESSMENTS
• Medical Reports and Specialty Assessments: Relevant medical reports including
specialty assessments (e.g., neurological evaluations, neuro-psychological, genetic testing,
etc.) for any qualifying diagnosis other than Intellectual Disability. These reports must
include the qualifying diagnosis, how it was arrived at, and how it impacts the person’s
functioning.
• Autism: If this person is diagnosed with autism, you must provide a report from a
comprehensive differential diagnostic assessment. This assessment must use structured
autism spectrum disorder-specific measures which are based on licensed clinician
observation of the person and considered to be reliable and valid. The report must include
a comprehensive developmental history. This includes information about the person’s
developmental milestones, repetitive behaviors, preoccupations, social interactions,
friendships, and other relevant information. The report must also include an observations
section that describes the person’s behavior during the evaluation in detail. In addition, the
diagnosis must include which specific symptoms of autism this person has and behavioral
descriptions of how the symptoms present in this person.
• Social History, Psycho-Social Report, or Other Background Information: This
information must indicate the presence of a developmental disability prior to age 22.
Background information is also needed if person being referred is age 17 or younger. This
report must include comprehensive social and background information (e.g., work history (if
any), living situations). Anecdotal information is especially important if routine
documentation is unavailable. A separate report may not be needed if sufficient
information is contained in other comprehensive evaluations.
OPWDD Guidance: Eligibility Guidelines Page 27 of 27
EDUCATIONAL RECORDS
• INDIVIDUALIZED EDUCATION PLAN (IEP) or 504 Accommodation Plan: The most
current plans should be submitted for school-aged people. Also include any
psychoeducational reports referenced in the plan. For those who are no longer in school
(e.g., no longer school aged, they have graduated), you should submit any school records
available.
• Early Intervention (EI): If the person has an EI plan, they should submit it. This includes
the Core Evaluation and progress notes, including a level of deficit for each domain.
ADDITIONAL INFORMATION
• All medical and/or clinical assessment reports must be signed by the clinician.
• Please DO NOT highlight or write on any documents.
• Additional information may be requested by OPWDD as needed.
